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Medicare for All is going to be the litmus test of progressivism in 2020. Legislation will soon be introduced in both chambers of Congress by Senator Bernie Sanders and Rep. Pramila Jayapal that would guarantee health care to every person in America. The bills come after a midterm election in which Democrats took back the House with dozens of candidates running on universal single-payer health care, some of them in deep red states.

A majority of House Democrats supported single payer in 2016, as did all of the 2020 hopefuls in the Senate. At the opening of this 116th Congress, House Speaker Nancy Pelosi announced her support for hearings on Medicare for All following the launch of the House Medicare for All Caucus last summer. (Though, out of the other side of her mouth that day, Pelosi oversaw the passage of “Paygo” legislation, an austerity measure that requires all new spending to be offset with deficit reduction.)

Recent polls tally support for Medicare for All at 70 percent, with 85 percent of Democrats and more than half (52 percent) of all Republicans. Single payer’s growing popularity, in and outside the Beltway, is a function of US lawmakers’ refusal to legislate an egalitarian health care system and a failure of neoliberalism more generally. Health care is a barometer of how a society values human life and how wealth and political power are distributed in it.

In the context of Democratic Party politics, neoliberal Democrats treat health care as a matter of consumer choice — a commodity distributed according to financial ability and subject to the vagaries of the “free” market. Medicare for All supporters, by contrast, argue that health care is a right that should be equally available to all — regardless of health status, income, employment, gender, immigration status, race, and ethnicity — that’s protected from the whims of business cycles and capitalist exploitation.

The Affordable Care Act (ACA) expanded access to private health insurance and Medicaid for tens of millions of Americans and prohibited insurance companies from denying coverage for preexisting conditions and canceling policies for expensive enrollees. It helped extend coverage to those who needed it most — women, people of color, and poor and working-class people. But the ACA also left some thirty million people uninsured and tens of millions more underinsured due to cost-prohibitive premiums, deductibles, and co-pays.

According to a 2017 Kaiser Family Foundation survey, 43 percent of adults — withhealth insurance — are struggling to afford their deductibles, and about a third cannot pay their premiums. Millions of people are declaring bankruptcy because of exorbitant medical bills, or are cutting back on food, clothing, or other basic needs to pay for care. Tens of millions are skipping or delaying treatment, and each year, tens of thousands die because they cannot get the care they need.

The fact that people are starving, going bankrupt, and dying because they lack health care has not stopped corporate Democrats from working to sabotage Medicare for All — especially in 2016, when Bernie Sanders’s presidential campaign popularized the idea. Bankrolled by big insurance, big pharma, and hospital systems, Clintonites and the Wall Street wing of the Democratic Party spared no expense to ensure that this highly profitable, multitrillion-dollar industry would not become a public good.

Despite the class antagonisms of 2016, once Trump took office, progressive and corporate Democrats joined forces to stave off the GOP’s multiple attempts to destroy the ACA and cut Medicaid and Medicare to pay for their $1.5 trillion tax cut for the rich. As a senior advisor in the Senate Budget Committee at the time, I accompanied Sanders on of one his “Don’t Take Our Health Care” tours aimed at pressuring Republican senators in Ohio, Pennsylvania, and West Virginia to oppose the legislation. That unified Democratic Party effectively put a stay on the GOP run of anti-ACA bills and marked an incredible victory for “the resistance” in the context of a fully Republican-controlled federal government.

That united front won’t hold in 2020, however.

Already, some of the presidential hopefuls who signed on to Sanders’s bill, namely Cory Booker and Kamala Harris, are waffling on whether Medicare for All should be a public good.

Plus, Obama administration and Hillary Clinton campaign alumni are teaming up with PhRMA, the American Medical Association (AMA), the BlueCross BlueShield Association, and a dozen other hospital and insurance lobbies to undermine Medicare for All in the court of public opinion.

Under the auspices of the Partnership for America’s Health Care Future, they plan to run ads, polls, and white papers to paint single payer as a disruptive, non-pragmatic, “one-size-fits-all, government-controlled system” that would restrict choice and innovation. Tellingly, that same pro-business red-baiting was echoed by Donald Trump in a recent USA Today op-ed, where he lamented the “planned government takeover of American health care.”

Medicare for All and Racial Disparities

In 2016, corporate Democrats exploited the rising discourse of racial justice around police violence in black communities and the Black Lives Matter movement, combining antiracist language with ideologies of austerity and the evils of “big government” to undermine universal public programs like Medicare for All and free public higher education.

In the lead up to the South Carolina primary, for example, where black voters are the Democratic majority, Rep. James Clyburn told voters that Bernie’s free public college legislation would undermine historically black colleges and universities — even though black students would disproportionately benefitfrom it and despite the fact that Sanders did have targeted funding in his bill to support those historically black institutions. Rep. John Lewis, for his part, insulted Bernie’s civil rights activism and used austerity politics to delegitimize key elements of his agenda, including universal health care:

There’s not anything free in America. We all have to pay for something. Education is not free. Health care is not free. Food is not free. Water is not free. I think it’s very misleading to say to the American people, we’re going to give you something free.

The contradictions manifest in Lewis’s remark are instructive. Corporate Democrats know that the failures of Obamacare — thirty million uninsured and tens of millions more underinsured due to exorbitant cost-sharing — have hit Latinx and black Americans the hardest. They also know that the closest thing to single payer in the United States, Medicare, has been effective in mitigating racial disparities among people aged sixty-five and over. Yet many of them still reject the idea that racial, gender, and class-based injustice could be alleviated through universal forms of public investment and an equitable redistribution of wealth.

That rejection was particularly ironic in Lewis’s case, since he, perhaps more than anyone else alive today, is aware that civil rights was about merging movements for black freedom with the general struggle of “the common man.” That fusion of racial and economic justice is embodied in A. Philip Randolph’s 1966 “A Freedom Budget for all Americans,” which offered a concrete policy agenda for universal access to proper medical care, quality housing, full employment, and higher education, in addition to other social goods, like a sound infrastructure and healthy environment.

June Eichner and Bruce C. Vladeck write in Health Affairs, “Because health care access and health status prior to Medicare eligibility are major determinants of beneficiaries’ health, improved access to care for other age groups should reduce health disparities. It could be argued that universal insurance for the entire population would have the largest impact on disparities of any strategy.”

In other words: extending Medicare to all Americans, as Sanders and Rep. Pramila Jayapal have proposed, could be an impactful step in mitigating racial disparities in American health care today.

By far the most successful part of the ACA was Medicaid expansion, which shows that expanding government programs is the cleanest, best way to provide people with health insurance. Studies on the quasi-single-payer system of the Veterans Administration (VA) also bear this out; in multiple measures of health, black patients actually do as well, or better, than their white counterparts.

That said, the Medicare program does have its limits. Racial discrimination is prevalent throughout our entire health care system, from clinical settings to insurance redlining to medical schools. Due to the racial wealth gap in America, many seniors of color cannot afford out-of-pocket costs for deductibles, coinsurance, and uncovered services. Plus, Medicare can only do so much when gross inequalities infect nearly all other social institutions and physical environments, and when the program is only available to people in their elder years.

Nonetheless, poor health outcomes among black Americans, due in large part to lack of access to care, would be significantly mitigated by instituting a universal health care program. That’s especially true if such disparities are addressed in terms of other social inequalities that particularly afflict black Americans — from mass incarceration to food deserts and environmental racism to school segregation and lack of health literacy, and many others.

Like Randolph’s Freedom Budget, for years Sanders has attempted to resolve America’s health care crisis by instituting a universal health care program, but also by legislating major investments in greening our infrastructure and strengthening our social institutions.

Single payer is not a silver bullet for confronting racial injustice in and beyond health care. We should also be targeting services and placing providers in underserved communities. But giving everyone comprehensive health insurance is absolutely essential to confronting those racial inequalities.

Medicare for All in 2020

In the prelude to 2020, Democrats have put several health care planson the table, all them claiming to serve those left behind by the ACA. Sanders and Jayapal’s plans are the only ones that are truly universal, though they all advertise expanded coverage and “access.”

What “access” really means, in Democratic parlance, is that people can buy affordable health insurance — they’re just not guaranteed affordable health care. Sanders and Jayapal excepted, all the proposed plans offer some combination of private and public insurance, which results in a fragmented system that does not contain costs and leaves drug and insurance companies in the driver’s seat.

The high price of deductibles, co-pays, and premiums is part of the reason why so many people remain underinsured under the ACA. The ACA did not break the link between health care and employment, and employer-sponsored insurance (ESI) premiums have been going up for decades as employers shift more and more costs onto their employees. Sanders and Jayapal’s bills are the only ones in the mix that do not involve cost-sharing.

And, by delinking health care from employment, their bills not only address the problem of unaffordable premiums, but also ensure that workers no longer have to stay at jobs they dislike just to keep their health care benefits. Under their plans, no American would have to delay or forego treatment because of an inability to pay, and no one would have to declare bankruptcy due to high medical costs.

Currently, the United States has the highest per-capita health care expenditures in the world, yet our health outcomes lag behind those of most other wealthy nations. Under the Sanders/Jayapal bills, the US health insurance system would be run by one public agency covering all residents equally and would not be treated as a commodity to be exploited by private companies.

The importance of putting health care in the public sector is something that presidential candidates like Cory Booker and Kamala Harris don’t seem to comprehend. By taking health care out of the hands of private insurers and allowing the government to negotiate prices, Medicare for All would lower administrative costs and eliminate waste and profiteering.

Given the clear benefits of single payer, why would any Democrat oppose it?

For those backed by Big Pharma and the insurance industry, it’s an obvious case of political self-interest. For others with less of a financial stake, it’s a matter of political courage. Medicare for All is not just about the institution of health care — it’s about how America distributes its resources. Cost-sharing is politically appealing because it reduces the tax revenue necessary to finance our health care system, and in neoliberals’ crass vernacular, forces patients to put “skin in the game.”

But it unfairly shifts the costs of health care from government and insurance companies onto individuals and families who are already struggling with stagnant wages and soaring costs of living.

In that vein, critical to Sanders’s health care agenda are policies related to jobs and other parts of the social system. For example, single-payer legislation must include robust provisions for transitioning health industry workers to the new system; a federal jobs guarantee such as the one Sanders is developing would offer an additional safety net.

Moreover, a clean environment, affordable housing, a living wage, access to good schools, higher education, and rewarding work all affect our wellness and quality of life. Sanders’s platform involves public sector investment in all of these aspects of the social matrix and physical environment.

If Democrats are genuinely interested in mitigating racial and gender disparities in our social institutions, they must start considering them in terms of the structure of the larger political economy. That means implicating the fundamentals of contemporary capitalism: the primacy of capitalist markets, profit motives, and ruling-class power, and the racial and gender ideologies that help legitimize them.

If Democrats are serious about defeating Donald Trump in 2020, they cannot continue to play footsie with drug and insurance companies and allow them to exploit our sick and our elderly. Sanders, if he runs, would be the only presidential candidate who has taken on corporate health care profiteers in the name of the working class and worked to pass Medicare for All through social movement pressure, not compromise.